Saturday, February 14, 2015

Infective endocarditis from injecting heroin into a leg ulcer

Drug addicts will often go to extreme lengths to obtain a high, completely disregarding their health. Intravenous drug use carries particularly many risks - including AIDS and hepatitis B infection if needles are reused and exchanged among addicts, but also abscesses, phlebitis (inflamed veins), gas gangrene, tetanus or sepsis, all caused by non-sterile injection technique. (If you saw the movie Requiem for a Dream, you may remember that one of the main characters ultimately had to have his arm amputated because of gangrene that developed after he repeatedly injected drugs into an already-inflamed vein.) A slightly less dramatic complication, also caused by dirty needles or injecting contaminated material, is infective endocarditis - inflammation of the inner tissue of the heart (such as its valves). The pathogens that cause it are usually bacteria, but other organisms can also be responsible. Damage to the valves can ultimately lead to heart failure.

The valves of the heart do not receive any dedicated blood supply. As a result, defensive immune mechanisms (such as white blood cells) cannot directly reach the valves via the bloodstream. If bacteria attach to a valve surface, the host's immune system cannot effectively attack them. The lack of blood supply to the valves also has implications for treatment, since drugs also have difficulty reaching the infected valve. Frequently, the infection damages the valves so severely that they must be surgically replaced.

Requiem for a Dream: what happens when you inject heroin with dirty needles

For those who think that Requiem for a Dream is overly drastic: I found a case report in PubMed that distinctly reminded me of Jared Leto's predicament as Harry, the junkie with phlebitis who kept injecting heroin into a seeping wound until his arm had to be amputated. The situation took place in the UK, in West Suffolk to be precise.  A 28-year-old male intravenous drug user was hospitalized with abdominal pain, sepsis (temperature 38.6°C, C-reactive protein 352 mg/l, white cell count 21.6×109/l) and dyspnea (91% oxygen saturation on 15 l/min oxygen). Physical examination revealed an early diastolic murmur, generalised abdominal guarding and a 12×8 cm necrotic leg ulcer . Detailed history revealed the patient was struggling with venous access and had resorted to injecting heroin into his leg ulcer (the latter can be seen below in all its gory glory). It turned out that he had severe infective endocarditis of the aortic valve. The infection had already destroyed his aortic valve cusps resulting in severe aortic regurgitation. Serial blood cultures subsequently revealed group A streptococcus infection for which a prolonged course of intravenous antibiotics was commenced. Three weeks later, the patient underwent open heart surgery to replace his aortic value. The leg ulcer slowly healed over the next few months.

An addict who repeatedly injected heroin into this leg ulcer developed infective endocarditis necessitating heart surgery. Image from: Thakor and Wijenaike (2009)

One thing really bugs me, I must say. I don't know much about the public health system in Great Britain, but I'm surprised that an active heroin addict was approved for open heart surgery. The article says nothing about the patient being treated for his addiction afterwards, e.g. being put on methadone.


Thakor AS, Wijenaike N. (2009) Infective endocarditis from injecting heroin into a leg ulcer. BMJ Case Rep. 2009: bcr07.2008.0493.

Wikipedia - Infective endocarditis


  1. I have heard of addicts getting open heart surgery. I believe it is transplants they are not likely to receive.

  2. I have heard of addicts getting open heart surgery. I believe it is transplants they are not likely to receive.